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      Rapid flattening of massive hemorrhagic retinal pigment epithelial detachment secondary to polypoidal choroidal vasculopathy after surgery

      case-report

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          Abstract

          Purpose

          To report 2 polypoidal choroidal vasculopathy (PCV) patients whose massive hemorrhagic pigment epithelial detachments (PEDs) were flattened within a short period after surgery.

          Observations

          Two PCV patients who presented with submacular hemorrhage and massive hemorrhagic PEDs with sizes of more than 50 disc areas underwent pars plana vitrectomy combined with subretinal injection of tissue plasminogen activator (tPA), intravitreous injection of anti-vascular endothelial growth factor medicine, and perfluoropropane tamponade. The massive hemorrhagic PEDs were flattened within a short period after both surgeries, and both patients experienced improved visual acuity.

          Conclusions

          These findings suggest that subretinal injection of tPA together with perfluoropropane tamponade promotes the rapid clearance of hemorrhage under RPE.

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          Most cited references12

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          Submacular hemorrhage in neovascular age-related macular degeneration: A synthesis of the literature.

          Dinu Stanescu-Segall, Florian Balta, Timothy L Jackson (2016)
          Large submacular hemorrhage, an uncommon manifestation of neovascular age-related macular degeneration, may also occur with idiopathic polypoidal choroidal vasculopathy. Submacular hemorrhage damages photoreceptors owing to iron toxicity, fibrin meshwork contraction, and reduced nutrient flux, with subsequent macular scarring. Clinical and experimental studies support prompt treatment, as tissue damage can occur within 24 hours. Without treatment the natural history is poor, with a mean final visual acuity (VA) of 20/1600. Reported treatments include retinal pigment epithelial patch, macular translocation, pneumatic displacement, intravitreal or subretinal tissue plasminogen activator, intravitreal anti-vascular endothelial growth factor (VEGF) drugs, and combinations thereof. In the absence of comparative studies, we combined eligible studies to assess the VA change before and after each treatment option. The greatest improvement occurred after combined pars plana vitrectomy, subretinal tissue plasminogen activator, intravitreal gas, and anti-vascular endothelial growth factor treatment, with VA improving from 20/1000 to 20/400. The best final VA occurred using combined intravitreal tissue plasminogen activator, gas, and anti-vascular endothelial growth factor therapy, with VA improving from 20/200 to 20/100. Both treatments had an acceptable safety profile, but most studies were small, and larger randomized controlled trials are needed to determine both safety and efficacy.
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            Management of thick submacular hemorrhage with subretinal tissue plasminogen activator and pneumatic displacement for age-related macular degeneration.

            Woohyok Chang, Sunir J Garg, Raj Maturi … (2014)
            To evaluate the outcome of pars plana vitrectomy, subretinal tissue plasminogen activator (t-PA) infusion and intraocular gas tamponade with and without postsurgical antivascular endothelial growth factor (VEGF) injection for thick submacular hemorrhage due to exudative age-related macular degeneration (AMD).
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              Management of submacular hemorrhage with intravitreal injection of tissue plasminogen activator and expansile gas.

              Claire Y Hooper, Daniel Tsun-Yee Chiu, Niral Karia … (2007)
              To evaluate the clinical outcome of intravitreal tissue plasminogen activator (tPA) and expansile gas injection as a minimally invasive treatment for submacular hemorrhage (SMH). This study was a retrospective clinical case series examining 104 eyes that received an intravitreal injection of 30-100 mcg of tPA and expansile gas (SF6 or C3F8) for SMH. The main outcomes evaluated were visual acuities (VA), anatomic displacement of submacular blood, and surgical complications. : A total of 85, 77, and 81 eyes were available at 1 week, 3 months, and 12 months follow up, respectively. Postoperatively, > or = 2 Snellen lines improvement were achieved in 43/85 eyes (51%) at 1 week, 49/77 eyes (63%) at 3 months, and 52/81 eyes (64%) at 12 months. Postoperative VA improvement was significantly associated with preoperative VA, submacular blood displacement, and the underlying cause of SMH. Diagnostic postoperative angiogram and clinical examination were possible at 8.2 +/- 7.4 weeks and 9.5 +/- 7.4 weeks, respectively. The observed complications included breakthrough vitreous hemorrhage in 8 eyes (8%) and retinal detachment in 3 eyes (3%). In this retrospective series, intravitreal injection of tPA and expansile gas was shown to be a safe and effective technique that can improve VA in most eyes with SMH and assist in the diagnosis of the underlying cause.
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                Author and article information

                Contributors
                Xiaoyun Fang
                Journal
                Journal ID (nlm-ta): Am J Ophthalmol Case Rep
                Journal ID (iso-abbrev): Am J Ophthalmol Case Rep
                Title: American Journal of Ophthalmology Case Reports
                Publisher: Elsevier
                ISSN (Electronic): 2451-9936
                Publication date PMC-release: 26 July 2023
                Publication date Collection: December 2023
                Publication date (Electronic): 26 July 2023
                Volume: 32
                Electronic Location Identifier: 101907
                Affiliations
                [a ]Eye Center, The Second Affiliated Hospital Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
                [b ]Ophthalmology Department, Ningbo Medical Centre Lihuili Hospital, Ningbo, China
                Author notes
                [∗ ]Corresponding author. xiaoyunfang@ 123456zju.edu.cn
                Article
                Publisher Item ID: S2451-9936(23)00115-9 Publisher ID: 101907
                DOI: 10.1016/j.ajoc.2023.101907
                PMC ID: 10407114
                SO-VID: f4a68fb0-1ebf-4c20-be60-cef0bb8019c9
                Copyright © © 2023 Published by Elsevier Inc.
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 1 March 2023
                Date revision received : 3 July 2023
                Date accepted : 20 July 2023
                Categories
                Subject: Case Report

                Keywords: hemorrhagic pigment epithelial detachment,pars plana vitrectomy,subretinal injection,tissue plasminogen activator
                Data availability:
                Keywords: hemorrhagic pigment epithelial detachment, pars plana vitrectomy, subretinal injection, tissue plasminogen activator

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